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Arizona rates for HCPCS A9513

Lutetium Lu 177 Dotate Therapeutic 1 Millicurie(Reinstated Code) Supply Of Radiopharmaceutical Diagnostic Imaging Agent Technitium Tc-99m Mebrofenin Per Mci (Old Description Deleted 12/31/2005)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$391.65 / $732.06 / $74,999.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$252.56 / $296.48 / $303.80
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$144.13 / $547.41 / $867.17
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$248.52 / $254.89 / $508.18
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$311.13 / $311.13 / $311.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$290.67 / $352.14 / $630.75
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $1,274.44
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$305.02 / $305.02 / $305.02